A 75 YEAR OLD MALE WITH ALTERED SENSORIUM
A 75 YEAR OLD MALE WITH ALTERED SENSORIUM
November 09, 2021
SOWJANYA REDDY PALAKURTHY
130
9Th semester
This is an online E-Log book to discuss our patient's de-identified data shared after taking his/her/Guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.
I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, Clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE:
A 75 years old diabetic male came to casualty with c/o altered sensorium.
CHIEF COMPLAINTS:
Unresponsiveness and difficulty in breathing since previous night.
HOPI:
Patient was apparently asymptomatic before the previous evening, he had his dinner and slept. Around midnight he made some sounds ( like snoring) and had involuntary movements for 2minutes and was unconscious and unresponsive.
Altered sensorium of sudden onset.
No h/o tongue bite, involuntary micturition.
No h/o previous seizures.
No h/o of vomiting and headache.
PAST HISTORY:
No similar complaints in past.
He is a k/c/o of Diabetes since 10 years and is on medication for the same.
Not a k/c/o HTN, CVA, CAD, TB, EPILEPSY, ASTHMA.
PERSONAL HISTORY:
- Diet- Mixed
- Appetite- Normal
- Bowel and bladder movements- Regular
- Sleep- Adequate
- Addictions- H/o alcohol consumption occasionally which he stopped 3years ago; cigarette smoking for 15years stopped 3 years ago.
SURGICAL HISTORY
No h/o previous surgeries.
FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
The patient was examined in a well-lit room after informed consent was taken.
The patient is unconscious.
He is well nourished and moderately built.
No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.
No signs of malnutrition/ dehydration.
VITALS:
- Temp-102°F
- PR-111bpm
- RR-20cpm
- BP-140/80mmHg
- SpO2-98% on 14L O2
- GRBS- 329mg/dL
SYSTEMIC EXAMINATION:
- CVS: S1, S2 Heard
- RS: BAE+, BARREL shaped chest present, B/L crepts heard in all lung fields.
- P/A: scaphoid, non tender, no organomegaly.
- CNS:
- Level of consciousness: COMA
- GCS: E1M1V1
- Pupils are mid dilated, unresponsive to light.
- Gag reflex PRESENT
- Neck stiffness PRESENT.
- REFLEXES- LEFT RIGHT
Biceps 2+ 2+
Triceps 2+ 2+
Supinator 2+ 2+
Knee 1+ 1+
Ankle 2+ 2+
Plantar Withdrawal Mute
INVESTIGATIONS:
HEMOGRAM
PROTHROMBIN TIME
KETONE BODIES
COMPLETE URINE EXAMINATION
HEPATITIS C
HEPATITIS B
ARTERIAL BLOOD GASES
HIV
RANDOM BLOOD SUGAR
RENAL FUNCTION TEST
GLYCATED HEMOGLOBIN
SERUM ELECTROLYTES
LIVER FUNCTION TEST
ECG
CT BRAIN
PROVISIONAL DIAGNOSIS:
Hypo-density of bilateral Cerebellar and Brainstem with ? VIRAL MENINGITIS, ? AKI 2° to SEPSIS, ? Aspiration Pneumonia, ? consolidation.
TREATMENT:
7/11/2021
- IVF- NS and RL @ 75ml/hr
- Inj. PIPTAZ 4.5g IV STAT then 2.25 IV/QID
- Inj. NEOMOL 1g IV/SOS (if temperature>101°F)
- Inj. PAN 40mg IV/OD
- Inj. ZOFER 4mg IV/TID
- Inj. OPTINEURON 1amp in 100ml ND IV/OD
- RT feeds-2nd hourly (3 scoops protein powder+ 150ml milk)
- ET/Oral suctioning- 3 hourly
- Inj. MIDAZ - 1mg/kg/hr (~60kg); no dilution- 1mg-1ml 1.2ml-6ml/hr(max dose)
- Inj. LEVIPIL 500mg IV/BD
- Air/ water bes
- Change of position every 2nd hourly
- DVT stockings
8/11/2021
- IVF- NS and RL @ 75ml/hr
- Head end elevation upto 30°
- Inj. NEOMOL 1g IV/SOS (if temperature>101°F)
- Inj. OPTINEURON 1amp in 100ml ND IV/OD
- Inj. PAN 40mg IV/OD
- Inj. ZOFER 4mg IV/TID
- Inj. LEVIPIL 500mg IV/BD
- Inj. DEXA 4mg/IV/BD
- Inj. ACYCLOVIR 500mg IV/TID
- RT feeds-2nd hourly (free water-100ml + protein powder-100ml)
- ET/Oral suctioning- 3 hourly
- Strict I/O charting- 2nd hourly
- BP, PR , SpO2 charting- hourly
- Inj. CEFTRIAXONE 2g/IV/BD
- Inj. MANNITOL 100mL/IV/BD
9/11/2021
- IVF- NS and RL @ 75ml/hr
- Head end elevation upto 30°
- Inj. NEOMOL 1g IV/SOS (if temperature>101°F)
- Inj. OPTINEURON 1amp in 100ml ND IV/OD
- Inj. PAN 40mg IV/OD
- Inj. DEXA 4mg/IV/BD
- Inj. ACYCLOVIR 500mg IV/TID
- RT feeds-2nd hourly (free water-100ml + protein powder-100ml)
- ET/Oral suctioning- 3 hourly
- Inj. CEFTRIAXONE 2g/IV/BD
- Inj. MANNITOL 100mL/IV/BD
- Strict I/O charting- 2nd hourly
- BP, PR , SpO2 charting- 4thhourly
